Summary Background Low birthweight is a significant risk factor for neonatal and infant death. A prominent cause of low birthweight is infection with Plasmodium falciparum during pregnancy. ...Antimalarial intermittent preventive therapy in pregnancy (IPTp) and insecticide-treated mosquito nets (ITNs) significantly reduce the risk of low birthweight in regions of stable malaria transmission. We aimed to assess the effectiveness of malaria prevention in pregnancy (IPTp or ITNs) at preventing low birthweight and neonatal mortality under routine programme conditions in malaria endemic countries of Africa. Methods We used a retrospective birth cohort from national cross-sectional datasets in 25 African countries from 2000–10. We used all available datasets from multiple indicator cluster surveys, demographic and health surveys, malaria indicator surveys, and AIDS indicator surveys that were publically available as of 2011. We tried to limit confounding bias through exact matching on potential confounding factors associated with both exposure to malaria prevention (ITNs or IPTp with sulfadoxine–pyrimethamine) in pregnancy and birth outcomes, including local malaria transmission, neonatal tetanus vaccination, maternal age and education, and household wealth. We used a logistic regression model to test for associations between malaria prevention in pregnancy and low birthweight, and a Poisson model for the outcome of neonatal mortality. Both models incorporated the matched strata as a random effect, while accounting for additional potential confounding factors with fixed effect covariates. Findings We analysed 32 national cross-sectional datasets. Exposure of women in their first or second pregnancy to full malaria prevention with IPTp or ITNs was significantly associated with decreased risk of neonatal mortality (protective efficacy PE 18%, 95% CI 4–30; incidence rate ratio IRR 0·820, 95% CI 0·698–0·962), compared with newborn babies of mothers with no protection, after exact matching and controlling for potential confounding factors. Compared with women with no protection, exposure of pregnant women during their first two pregnancies to full malaria prevention in pregnancy through IPTp or ITNs was significantly associated with reduced odds of low birthweight (PE 21%, 14–27; IRR 0·792, 0·732–0·857), as measured by a combination of weight and birth size perceived by the mother, after exact matching and controlling for potential confounding factors. Interpretation Malaria prevention in pregnancy is associated with substantial reductions in neonatal mortality and low birthweight under routine malaria control programme conditions. Malaria control programmes should strive to achieve full protection in pregnant women by both IPTp and ITNs to maximise their benefits. Despite an attempt to mitigate bias and potential confounding by matching women on factors thought to be associated with access to malaria prevention in pregnancy and birth outcomes, some level of confounding bias possibly remains. Funding Malaria Control and Evaluation Partnership in Africa (MACEPA), Bill & Melinda Gates Foundation.
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Belatacept, a selective T-cell costimulation blocker, was associated with improved survival and renal function but also with a risk of posttransplant lymphoproliferative disorder (PTLD) in adult ...kidney transplant recipients in phase 3 trials. This registry examined long-term safety in Epstein-Barr virus (EBV)-seropositive kidney transplant recipients treated with belatacept.
This US-based, prospective, voluntary, multicenter registry (Evaluating Nulojix Long-Term Safety in Transplant ENLiST) included adult EBV-seropositive kidney-only transplant recipients treated de novo (within 14 d of transplantation) with belatacept. Primary objectives were to estimate incidence rates of confirmed PTLD, central nervous system (CNS) PTLD, and progressive multifocal encephalopathy (PML). The minimum follow-up was 2 y.
Of 985 enrolled transplant recipients, 933 EBV-seropositive patients received belatacept, with 523 (56.1%) receiving concomitant tacrolimus at transplant (for up to 12 mo). By study end, 3 cases of non-CNS PTLD (incidence rate, 0.08/100 person-years), 1 case of CNS PTLD (0.03/100 person-years), and no cases of PML had been reported. Two patients with non-CNS PTLD received concomitant belatacept and tacrolimus and 1 received belatacept and lymphocyte-depleting therapy. Incidence rates were comparable between patients who received concomitant belatacept and tacrolimus and those who did not receive tacrolimus (0.09/100 person-years and 0.07/100 person-years, respectively;
= 0.96). Two of 4 patients with PTLD died, and 2 were alive at the end of the study. Cumulatively, 131 graft losses or deaths were reported by study end.
Our results from the ENLiST registry, a large, prospective real-world study, showed that the incidence rates of PTLD and CNS PTLD in belatacept-treated EBV-seropositive transplant recipients were consistent with findings from previous phase 3 trials.
Approximately 20.8 million people in the United States, or 7% of the population, have diabetes mellitus. Treatment for this disease costs Americans more than 130 billion dollars yearly, and it is the ...sixth leading cause of death. The prevalence of diabetes has grown substantially in recent decades and is expected to continue to rise.
The medically underserved and poor are at greater risk of developing diabetes and its complications than are other members of the U.S. population. The Health Resources and Services Administration makes health care resources and services available to economically disadvantaged populations through the Health Disparities Collaborative (HDC), a consortium formed to pool resources and services from state- and community-level donors. Since 1999, many of the Centers for Disease Control and Prevention's Division of Diabetes Translation State Diabetes Prevention and Control Programs (DPCPs) have joined the HDC to leverage resources and services.
The purpose of a 2004 evaluation was to examine the impact that DPCP involvement with the Collaborative had on aspects of diabetes care at Federally Qualified Health Centers (FQHCs). An electronic survey was administered to DPCP coordinators. They were asked about 1) their roles and experience as participants in the Collaborative; 2) the skills and expertise most useful in developing and maintaining an effective collaboration for improved health care for diabetes; 3) which DPCP contributions were viewed as being routine and which were perceived to be essential; 4) the effects of DPCP contributions on the use of the chronic care model under which FQHCs operate; and 5) which health systems improvements played the greatest role in enhancing components of the chronic care model.
Most respondents identified themselves as DPCP coordinators with 3 years of experience in that position. Organizational skills, such as communication, leadership, conflict resolution, negotiation, and meeting management, were cited as necessary to develop and maintain collaborative partnerships. DPCP contributions to FQHCs were perceived to be training, technical assistance with clinical care and patient education, financial resources, linkages to other diabetes partners, educational materials, and improved linkages with community resources.
DPCPs contribute resources, skills, knowledge, and varied perspectives to the Collaborative that FQHCs may not have otherwise.
Summary Background Closed-loop systems link continuous glucose measurements to insulin delivery. We aimed to establish whether closed-loop insulin delivery could control overnight blood glucose in ...young people. Methods We undertook three randomised crossover studies in 19 patients aged 5–18 years with type 1 diabetes of duration 6·4 years (SD 4·0). We compared standard continuous subcutaneous insulin infusion and closed-loop delivery (n=13; APCam01); closed-loop delivery after rapidly and slowly absorbed meals (n=7; APCam02); and closed-loop delivery and standard treatment after exercise (n=10; APCam03). Allocation was by computer-generated random code. Participants were masked to plasma and sensor glucose. In APCam01, investigators were masked to plasma glucose. During closed-loop nights, glucose measurements were fed every 15 min into a control algorithm calculating rate of insulin infusion, and a nurse adjusted the insulin pump. During control nights, patients' standard pump settings were applied. Primary outcomes were time for which plasma glucose concentration was 3·91–8·00 mmol/L or 3·90 mmol/L or lower. Analysis was per protocol. This trial is registered, number ISRCTN18155883. Findings 17 patients were studied for 33 closed-loop and 21 continuous infusion nights. Primary outcomes did not differ significantly between treatment groups in APCam01 (12 analysed; target range, median 52% IQR 43–83 closed loop vs 39% 15–51 standard treatment, p=0·06; ≤3·90 mmol/L, 1% 0–7 vs 2% 0–41, p=0·13), APCam02 (six analysed; target range, rapidly 53% 48–57 vs slowly absorbed meal 55% 37–64, p=0·97; ≤3·90 mmol/L, 0% 0–4 vs 0% 0–0, p=0·16), and APCam03 (nine analysed; target range 78% 60–92 closed loop vs 43% 25–65 control, p=0·0245, not significant at corrected level; ≤3·90 mmol/L, 10% 2–15 vs 6% 0–44, p=0·27). A secondary analysis of pooled data documented increased time in the target range (60% 51–88 vs 40% 18–61; p=0·0022) and reduced time for which glucose concentrations were 3·90 mmol/L or lower (2·1% (0·0–10·0) vs 4·1% (0·0–42·0); p=0·0304). No events with plasma glucose concentration lower than 3·0 mmol/L were recorded during closed-loop delivery, compared with nine events during standard treatment. Interpretation Closed-loop systems could reduce risk of nocturnal hypoglycaemia in children and adolescents with type 1 diabetes. Funding Juvenile Diabetes Research Foundation; European Foundation for Study of Diabetes; Medical Research Council Centre for Obesity and Related Metabolic Diseases; National Institute for Health Research Cambridge Biomedical Research Centre.
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Objective The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database aims to reduce 30-day post-operative complications. Reduction of post-operative stroke ...and coma can decrease length and cost of hospitalization, improve patient functional status and decrease morbidity and mortality. Methods We performed a search of the ACS-NSQIP database for all patients undergoing an operation with a surgeon whose primary specialty was neurological surgery from 2006 to 2013. Results Of 94,546 neurosurgical patients reported, there were 687 (0.71%) cases of post-operative stroke and coma. The annual rate of coma longer than 24 hours decreased from 0.90% in 2006 to 0.002% in 2013 (p<0.001), while the annual rate of stroke decreased from 1.2% in 2006 to 0.5% in 2013 (p=0.013).. Multivariate analysis demonstrated that inpatient status (p=0.001), age (p=0.005, OR=1.012), history of diabetes (p=0.017, OR=1.515), ventilator dependence (p<0.001, OR=4.379), impaired sensorium (p<0.001, OR=2.314), history of coma longer than 24 hours (p<0.001, OR=2.655), hemiparesis (p=0.022, OR=1.492), CVA/stroke with neurological deficit (p<0.001, OR=2.091), CVA/stroke without neurological deficit (p=0.001, OR=2.44), and tumor involving CNS (p<0.001, OR=2.928) are significant risk factors for developing post-neurosurgical stroke and coma. Conclusions The rate of post-neurosurgical stroke decreased from 1.2% in 2006 to 0.5% in 2013 and the rate of post-neurosurgical coma greater than 24 hours decreased from 0.9% in 2006 to 0.002% in 2013. Ten risk factors for developing post-neurosurgical stroke and coma were identified using multivariable analysis. These risk factors should be assessed pre-operatively and incorporated into clinical decision making so individuals whom are at higher risk for the development of stroke and coma can be appropriately monitored during the post-operative period.
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The survival benefit of heart transplantation in adult heart failure is greatest for the sickest patients and negligible for patients not requiring inotropic or mechanical support. We hypothesized a ...similar survival benefit of heart transplantation for childhood cardiomyopathies with heart failure.
A merged data set of children registered in both the Pediatric Cardiomyopathy Registry and the Pediatric Heart Transplant Study was used to assess differences in mortality before and after transplant in patients with different levels of heart failure severity. Severity was scored 2 if mechanical ventilatory or circulatory support was required, 1 if intravenous inotropes were required, or 0 if no support was required.
For 332 eligible children, 12-month mortality after listing was 9% for those with a severity score of 0 (n = 105), 16% with a score of 1 (n = 118), and 26% with a score of 2 (n = 109; p = 0.002) with a 3%, 8%, and 20% mortality with severity scores at listing of 0, 1, and 2, respectively, occurring before transplant. Patients listed with a score of 0 frequently deteriorated: 50% received an allograft or died before transplant with severity scores of 1 or 2. The risk of deterioration increased with previous surgery (relative risk, 3.84; p = 0.03) in the short-term and with lower left ventricular mass z-score at time of presentation (relative risk, 1.74; p = 0.003) in the longer-term.
Pediatric cardiomyopathy patients who require high levels of support receive a survival benefit from heart transplantation that is not shared by patients not requiring intravenous inotropic or mechanical support.
Background Impaired physical fitness, a contributor to obesity and cardiovascular disease, has been associated with both an individual's socioeconomic status (SES) and with residence in disadvantaged ...neighborhoods. The aim of the study was to examine the extent to which neighborhood socioeconomic status (SES) is associated with impaired fitness, independent of clinical characteristics and individual-level SES. Methods Two thousand five hundred five participants 25 to 42 years old examined in the CARDIA study from 1992 to 1993 underwent symptom-limited exercise stress testing. Physical fitness was considered impaired if metabolic equivalents were in the lowest sex-specific quintile. Neighborhood SES was determined for each census tract using 1990 census data. Generalized estimating equations assessed the association between neighborhood SES and physical fitness, before and after adjustments for individual SES, sociodemographic, and clinical characteristics, and accounted for clustering within census tracts. Results Individuals in disadvantaged neighborhoods had lower educational attainment and income, and were more likely unemployed, black, and uninsured. The odds ratio (95% CI) for impaired physical fitness in the lowest vs highest tertile of neighborhood SES was 5.8 (3.7-7.3). These became 3.9 (2.7-5.7) after adjusting for individuals' educational attainment, personal income, employment status, and ability to pay for basic needs; and 1.9 (1.2-2.9) after additional adjustment for other sociodemographic and clinical factors. Conclusions Features of one's neighborhood of residence are relevant to cardiovascular health. A health policy perspective that looks beyond an individual's characteristics may therefore be useful in identifying more effective interventions to reduce the prevalence of low physical fitness and its consequences in young adults.
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Abstract Background Emergency medical services (EMS) personnel commonly encounter sepsis, yet little is known about their understanding of sepsis. Study Objectives To determine the awareness, ...knowledge, current practice, and attitudes about sepsis among EMS personnel. Methods We performed an anonymous, multi-agency, online survey of emergency medical technicians (EMTs), firefighter-emergency medical technicians (FF-EMTs), and paramedics in a metropolitan, 2-tier EMS system. We compared responses according to the level of EMS training and used multivariable logistic regression to determine the odds of correctly identifying the definition of sepsis, independent of demographic and professional factors. Results Overall response rate of study participants was 57% (786/1390), and was greatest among EMTs (79%; 276/350). A total of 761 respondents (97%) had heard of the term “sepsis.” EMTs and FF-EMTs were at significantly reduced odds of correctly defining sepsis compared to paramedics, independent of age, sex, and years of experience (EMTs: odds ratio 0.44, 95% confidence interval 0.3–0.8; FF-EMTs: odds ratio 0.32, 95% confidence interval 0.2–0.6. Overall, knowledge of the clinical signs and symptoms and recommended treatments for sepsis was typically > 75%, though better among paramedics than EMTs or FF-EMTs ( p < 0.01). The majority of respondents believed sepsis is not recognized by EMS “some” or “a lot” of the time (76%, 596/786). Conclusions EMS personnel demonstrated an overall sound awareness of sepsis. Knowledge of sepsis was less among FF-EMTs and EMTs compared to paramedics. These results suggest that paramedics could be integrated into strategies of early identification and treatment of sepsis, and EMTs may benefit from focused education and training.
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Highlights • In this study of 132,063 NSQIP-reported neurosurgical patients, 5.3% developed postoperative infections • Postoperatively, 1.8% of patients developed surgical site infections (SSI) and ...3.9% developed other infections including pneumonia, urinary tract infections, or systemic inflammatory response syndrome (SIRS); SSI were late complications relative to other postoperative infections • Risk factors for postoperative infections after neurosurgery included female sex, older age, obesity, functionally dependent status prior to surgery, ventilator dependence, preoperative steroid use, bleeding disorders, preoperative SIRS, hyponatremia, lymphocytosis, anemia, thrombocytosis, emergent case status, wound class II-IV, American Society of Anesthesiologists (ASA) class 3-5, and longer operative times.
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Often the topic is the subject of considerable ongoing investigation. ...the reader should view the ECD as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice ...in areas where rigorous evidence may not yet be available or evidence to date is not widely applied to clinical practice. All participating organizations participated in peer review, resulting in 22 reviewers representing 170 comments.\n Anderson Content Reviewer--ACCF Unstable Angina Guideline BSCI/sanofi None None AstraZeneca (DSMB) Gilead Pharma (DSMB) Hamilton Health Sciences University (DSMB) Harvard (DSMB) NIH (DSMB) Toshiba Deseret Foundation, Intermountain Healthcare NIH Defendant, management of cardiopulmonary arrest post-op, 2010 Defendant, stroke after ablation for AF, 2010 James A. de Lemos Content Reviewer--ACCF Task Force on CECD Johnson & Johnson Tethys Bristol-Myers Squibb/sanofi-aventis partnership* None Bristol-Myers Squibb (DSMB) Roche Diagnostics* AstraZeneca* Daiichi Sankyo None Robert A. Guyton Content Reviewer--ACCF CABG Guideline None None None Edwards Lifesciences NIH None None Richard J. Kovacs Content Reviewer--ACCF Abbott Laboratories Biomedical Systems Cook* ECG Scanning and Medical Services* Eli Lilly* Endocyte Essentialis XenoPort None None None None None Frederick G. Kushner Content Reviewer--ACCF STEMI Guideline FDA None Bristol-Myers Squibb Merck Roche Holding* Daiichi Sankyo Hoffmann La Roche NIH Novartis FDA Science Board None David Lanfear Content Reviewer--ACCF Heart Failure and Transplant Committee Thoratec None None sanofi-aventis* Johnson & Johnson* HFSA None John F. Robb Content Reviewer--ACCF None None None None None None Sidney C. Smith, Jr. Relationships in this table are modest unless otherwise noted.AACC = American Association for Clinical Chemistry; ACCF = American College of Cardiology Foundation; ACCP = American College of Chest Physicians; ACP = American College of Physicians; AF = atrial fibrillation; AHA = American Heart Association; CABG = coronary artery bypass graft surgery; CECD = Clinical Expert Consensus Documents; DSMB = Data and Safety Monitoring Board; FDA = Food and Drug Administration; HFSA = Heart Failure Society of America; NIH = National Institutes of Health; PCI = percutaneous coronary intervention; SCAI = Society for Cardiovascular Angiography and Interventions; STEMI = ST-segment elevation myocardial infarction; UA = unstable angina.
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